A. Radiographs, when needed, should be taken in anteroposterior, oblique, and lateral views. These films may be supplemented with an open-mouth view of the odontoid or flexion-extension films when instability is suspected. In cases of mild neck pain, a therapeutic trial for osteoarthritis might be tried before radiography is ordered. As symptoms and signs worsen, radiographic procedures become more appropriate.
1. Alignment of the spine in the anteroposterior and lateral projections should be evaluated.
a. The anteroposterior film should reveal approximately the same distance between spinous processes.
b. The lateral film should reveal vertebral bodies forming a gentle curve that is concave posteriorly.
2. Narrowing of the disk space is best seen on the lateral view. Such narrowing is most commonly seen at the C5-6 level, followed by the C6-7 and C4-5 levels.
3. The oblique view should demonstrate neural foramina of relatively uniform size through which the cervical nerve roots traverse. Isolated narrowing or the presence of an osteophyte may sometimes be identified.
4. The uncovertebral joints (joints of Luschka) are best seen on the anteroposterior view; cervical osteoarthritis often leads to narrowing of these joints.
5. The presence of a cervical rib should be noted as well.
6. Congenital fusions of cervical vertebrae or other bony anomalies may be present. B. Further diagnostic studies
1. Magnetic resonance imaging is an excellent way to visualize the spinal cord and soft tissues in relation to bony anatomy.
2. Computed tomography is useful in determining spinal stenosis and areas of nerve root compression by osteophytes.
3. Myelography is indicated in patients with intractable neck pain and radiculopathy to localize spinal cord or nerve root compromise by disk, osteophyte, neoplasm, or other space-occupying process. Originally used in conjunction with plane radiographs, myelography is now often performed along with computed tomography in an effort to visualize the canal better (see section IV B.:.2).
4. Bone scan may demonstrate osseous involvement by neoplasm, vertebral compression fracture, or infection in the cervical spine.
5. Electromyography may be useful in demonstrating spinal stenosis and areas of nerve root compression by osteophytes.
6. Standard blood work may reveal abnormal values, such as an elevated white blood cell count, erythrocyte sedimentation rate, or serum glucose level (in diabetic patients), that suggest an infectious process.
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